RESPONSIBILITY: Clinician, Mirco Nacoti
Mirco Nacoti,
MD, (ITALY) , is an emergency, anesthesia and intensive care
physician at Bergamo Hospital, Italy. An expert in international health
and bioethics, he has extensive field experience in humanitarian crises
and community approach to vulnerable people.
Two months after the beginning of the crisis I still have major problems
sleeping.
I’ve dragged the corpse, from the bathroom to the bedroom, of a 50 years
old man who had died at home.
I’ve seen dozens of people piled up in emergency rooms with severe
dyspnoea and frightened eyes.
I’ve spoken on the phone to a friend of mine and said to her: you must
choose between your father and your mother.
I’ve run at night to my hospital, taken a drug for sedation and come
back to look after an old man dying, as my hospital was too crowded.
I’ve obeyed an order to transfer to Germany by flight an intubated man
and he has died on his way. I’ve never spoken to his parents.
I know many young anaesthetists in my hospital who have decided alone
who were to live and who were to die.
I feel a persistent smell of people suffering on my skin.
The pale light of an old humanitarian actor, with some studies in
bioethics, is now a fire. 40 years later, the Alma Ata definition (2) of
primary health care seems vital to me.
I’ve done and watched a lot over these past 2 months. But my night-time
question is: have I thought enough? That’s why I’m very grateful to have
this occasion to think.
Bergamo is a rich and populous city of northern Italy (1.000.000 people)
and one of the epicentres of the worldwide COVID 19. Despite the
generosity of health workers, we are undergoing a severe humanitarian
crisis that is stressing every aspect of daily life.
From outside it is very hard to understand, because houses are closed
for lockdown and are not destroyed as they would be in an earthquake.
Furthermore, in regard to the dilemma of moral responsibility, the World
Health Organisation figures do not represent the reality. WHO is doing a
great job, as usual, but the figures provided are a dilemma, as usually
occurs during an outbreak. Today WHO shows about 3.500.000 confirmed
cases with 240.000 deaths (3) worldwide and in Bergamo 13.000 confirmed
cases with about 2500 deaths (4). Unfortunately, the actual deaths
reported by town halls are about 6.000-7.000 (nearly 1% of the
population) (5). Considering that a fatality rate of 20% is a
non-sense, because the Chinese experience (even in Hubei province)
reports a rate between 1 and 3% (6), the number of people contaminated
in Bergamo is likely to be between 250.000 and 500.000 (which means
25%-50% of the population). More than 2.000 people with mild-severe
hypoxia, at the peak of the outbreak, stayed home because all the
hospitals were overcrowded. These are the real figures. This is the
picture of Bergamo’s disaster.
For this reason we wrote a paper which appeared in the New England
Journal (7). In regard to the dilemma of moral responsibility, when the
global medical community is called on to face a pandemic of
unprecedented scale, with little scientific evidence and “crazy
numbers” describing the situation, honest and forthcoming advocacy is
an ethical duty, and that paper was a wake-up call for those involved in
system preparedness and strategic planning.
An outbreak is neither a simple disaster casualty incident like an
earthquake or a “simple” disease, but it’s a social phenomenon.
Historical and social elements are key factors for development (for
example, intensive promiscuity between animals and humans) and spread
(for example health workers and ambulance rapidly become vector of the
virus) of an epidemic (7).
A first consequence of this translation into a social horizon concerns
the theme of responsibility. And in regard to the dilemma of moral
responsibility, how much does the social narrative about the infection
numbers weigh, for example, on the decisions to be taken and on the
concepts that guide them (for example, that of proportionality)?
How do inaccurate narratives, from an epidemiological point of view,
affect the ”judgment in situation”, that takes place in triage or in
prevention strategies in other countries? How many shocking images are
needed if figures are not reliable ?
Another aspect of the dilemma of moral responsibility concerns the care
of decision-making process and the fragmentation of responsibility.
Modern western medicine has centralized the care of patients in the
hospitals (and our region does represent this process), preventing the
community from being the main actor in the sphere of public health and
putting into practice an “expropriation of health”, as Ivan Illich’
says in Medical Nemesis (8). Body has been progressively fragmented in
small pieces by super-specialized doctors and responsibility has ended
up being a question of legal responsibility, an economic matter, and not
an ethical one. In this fragmentation, it has been acceptable for us to
execute orders, even if epidemically dangerous or not ethical, because
we were living an urgent situation, and during the fight against COVID
19 the mantra was “to do and not to think”. It seems, as Hannah Arendt
writes in her ”Banality of evil”, that “nobody was responsible, or
rather, nobody felt they were; they just did their job” (9). Would have
been useful to have a mechanism of control of decision makers in close
contact with territories? Only the awareness that the weight of a
decision is to be shared can prevent us from turning the triage into a
moment of irresponsible superhomism.
A further aspect of the dilemma of moral responsibility is the ethics of
the research in urgent situation. As Derek C. Angus wrote in a JAMA view
point (10), one stark example is the debate over prescribing available
drugs, such as chloroquine, or testing these drugs in randomized
clinical trials. At the heart of the problem is one of the oldest
dilemmas in human organizations: the “exploitation-exploration” trade
off. Exploitation refers to the “just do it” option. Exploration
refers to the “must learn” option.
During his captivity in the 1940s, Archibald Cochrane treated many
prisoners, often ill with tuberculosis, by observing how the disease
benefited more from a good caloric intake than from drugs of uncertain
or zero efficacy. The germs of Evidenced Based Medicine arose from those
observations. 80 years later, in regard to the dilemma of moral
responsibility, how many helmets to deliver respiratory assistance have
been placed without any enteral feeding in Bergamo? Chloroquine,
antiviral, anti IL6, anti-complement, steroids, antibiotics have been
distributed without a real methodological approach, without monitoring,
with people arriving at the hospital worn out after days of dyspnoea.
What data, what ethical research can be produced in such a mess, what if
you publish on an important indexed medical journal but the
”garbage in, garbage out” approach is still considered the right
one (11)? Furthermore, in regard to the dilemma of moral responsibility,
what about signatures extorted for consensus from a dyspneic patient
with no family member nearby? Such a touchy a matter would require
competence and experience, and yet it was often managed by residents
instead of specialists. Not everything is lawful in urgency and there is
an ethics of research even in urgency.
Derek C. Angus suggests at the end of Jama view point (10) that an
integrated approach of “learning while doing” is essential in a
crisis. Nevertheless, in our current context, it’s very important not to
lose the capacity to think and probably we have to subtly shift from
Angus’ suggestion to a “thinking/learning while doing”, as Hannan
Arendth writes (12).
Goisis, a philosopher coauthor of the New England article, says that it
is not true that nothing will be as it used to be before COVID 19.
Millions of people in the world will be more vulnerable and isolated.
But the economic, scientific, political and social mechanisms leading to
this pandemic humanitarian disaster are still there. “Doctors have to
give back to the community the capacity to promote health”, could have
said Ivan Illich today.